Outcome of patients with acute bacterial meningitis in a ...
Appropriate Antibiotic Use & Clinical Outcome Acute ...
28
11 May, 2006 Appropriate Antibiotic Use & Clinical Outcome Appropriate Antibiotic Use & Clinical Outcome in in Acute Medical Wards Acute Medical Wards Dr. Chan Kai Ming Dr. Chan Kai Ming Associate Consultant Associate Consultant Infectious Disease Management Infectious Disease Management Tuen Tuen Mun Mun Hospital Hospital
Transcript of Appropriate Antibiotic Use & Clinical Outcome Acute ...
11 May, 2006
Appropriate Antibiotic Use & Clinical OutcomeAppropriate Antibiotic Use & Clinical Outcomeinin
Acute Medical WardsAcute Medical Wards
Dr. Chan Kai MingDr. Chan Kai MingAssociate ConsultantAssociate Consultant
Infectious Disease ManagementInfectious Disease ManagementTuenTuen MunMun HospitalHospital
11 May, 2006
IntroductionIntroduction
•• Antibiotics are powerful weapons against Antibiotics are powerful weapons against infection diseasesinfection diseases
•• Best use of antibiotics requires good Best use of antibiotics requires good knowledge ofknowledge of–– Pharmacokinetics and Pharmacokinetics and pharmacodynamicspharmacodynamics of of
antibioticsantibiotics–– Characteristics of pathogens Characteristics of pathogens –– Characteristics of diseasesCharacteristics of diseases–– Characteristics of patientsCharacteristics of patients
11 May, 2006
IntroductionIntroduction
•• July 2004July 2004–– First Audit in our HospitalFirst Audit in our Hospital–– Among 106 patients, Among 106 patients, –– 66% appropriateness in antibiotics use in 66% appropriateness in antibiotics use in
acute medical wards.acute medical wards.–– A series of case reviewsA series of case reviews–– Presentations and talksPresentations and talks–– Distribution of guidelinesDistribution of guidelines
11 May, 2006
ObjectivesObjectives
•• To audit the appropriateness in antibiotic To audit the appropriateness in antibiotic usage and outcomes in acute medical usage and outcomes in acute medical wards of Department of Medicine & wards of Department of Medicine & Geriatrics, Geriatrics, TuenTuen MunMun Hospital after one Hospital after one year of ongoing intervention measures.year of ongoing intervention measures.
11 May, 2006
MethodsMethods
•• PeriodPeriod–– 2525thth July 2005 to 7July 2005 to 7thth August 2005August 2005
•• Patients admitted to acute medical wardsPatients admitted to acute medical wards•• Concurrent daily assessment until Concurrent daily assessment until
discharge, transferred out or a maximum discharge, transferred out or a maximum of two weeks of two weeks
11 May, 2006
MethodsMethods
•• AssessmentAssessment–– Appropriateness in antibiotic useAppropriateness in antibiotic use–– ManagementManagement–– Clinical detailsClinical details
•• DiagnosisDiagnosis•• Use of antibioticsUse of antibiotics•• Length of stayLength of stay•• MortalityMortality
11 May, 2006
ResultsResults
11 May, 2006
107 Admissions, 59 patients used antibiotics (55%)
Appropriate Use,35, 59%
(95%CI 46.8% -71.8%)
InappropriateInitiation, 10,
17%
InappropriateChoice of
Antibiotics, 7,12%
Duration, Dosage& Route of
Administration, 7,12%
11 May, 2006
Diagnosis
UTI 11 19%
Bone & SoftTissue 2 3%
Viral Infection 23%
Sepsis 1 2%URTI 1 2%
Biliary Sepsis 1 2%
Not Infection 1220%
Chest Infection 2949%
11 May, 2006
Individual performance
0%
20%
40%
60%
80%
100%
Not Infection
Chest infection
UTI Bone & Soft Tissue
Viral Infection
SepsisURTI
Biliary Sepsis
Appropriate Indication Choice Adminsitration
11 May, 2006
Individual performance
0%
20%
40%
60%
80%
100%
Not Infection
Chest infection
UTI Bone & Soft Tissue
Viral Infection
SepsisURTI
Biliary Sepsis
Appropriate Indication Choice Adminsitration
11 May, 2006
Individual performance
0%
20%
40%
60%
80%
100%
Not Infection
Chest infection
UTI Bone & Soft Tissue
Viral Infection
SepsisURTI
Biliary Sepsis
Appropriate Indication Choice Adminsitration
11 May, 2006
Individual performance
0%
20%
40%
60%
80%
100%
Not Infection
Chest infection
UTI Bone & Soft Tissue
Viral Infection
SepsisURTI
Biliary Sepsis
Appropriate Indication Choice Adminsitration
11 May, 2006
Amox/clav59%
Amp/Sulb4%
Cloxacillin1%
Cefuroxime11%
Acyclovir1% Ceftriaxone
4%
Cefoper/Sulb3%
Levofloxacin8%
Ciprofloxacin4%
Azithromycin1%
Clarithromycin1%
Imipenem/cila3%
Other25%
Antibiotics useAntibiotics use
11 May, 2006
OutcomesOutcomes
85.7 per 100085.7 per 1000
2.86 days2.86 days
3 days3 days
Antibiotics Antibiotics appropriately appropriately usedused
p = 0.68p = 0.68125 per 1000125 per 100032.3 per 100032.3 per 1000MortalityMortality
p = 0.038p = 0.0384.6 days4.6 days2.47 days2.47 daysMean Length Mean Length of Stayof Stay
p = 0.016p = 0.0164 days4 days2 days2 daysMedian Median Length of Length of StayStay
Antibiotics NOT Antibiotics NOT appropriately appropriately usedused
Antibiotics Antibiotics not usednot used
11 May, 2006
DiscussionDiscussion
•• Education alone intervention did not result Education alone intervention did not result in higher rate of appropriate antibiotics usein higher rate of appropriate antibiotics use
•• Other factorsOther factors–– On going recruitment of junior doctorsOn going recruitment of junior doctors–– Unchanged antibiotics prescribing Unchanged antibiotics prescribing behavioursbehaviours
•• Insufficient information Insufficient information vsvs inappropriate inappropriate behavioursbehaviours
11 May, 2006
DiscussionDiscussion
•• Other Other centrescentres–– Hartford Hospital, USAHartford Hospital, USA
•• 54.4% received recommendation. Arch Intern Med 54.4% received recommendation. Arch Intern Med 19881988
–– University of Vermont College of Medicine, University of Vermont College of Medicine, USAUSA•• 49% received suggestions in the intervention 49% received suggestions in the intervention
group. Arch Intern Med 1997group. Arch Intern Med 1997–– Teaching Hospital in ParisTeaching Hospital in Paris
•• Two Third appropriate. Two Third appropriate. PressePresse Med 2003Med 2003
11 May, 2006
DiscussionDiscussion
•• Other Other centrescentres–– Christian Medical College & Hospital, Christian Medical College & Hospital, VelloreVellore, ,
India. J India. J ClinClin EpidEpid 19961996•• 67% appropriate at the primary level67% appropriate at the primary level•• 60% at the tertiary level60% at the tertiary level
–– Brazil Teaching Brazil Teaching CentresCentres•• Therapeutic used was considered inadequate in Therapeutic used was considered inadequate in
27%. 27%. BrazBraz J Infect J Infect DisDis 20042004
11 May, 2006
22 22 –– 65% of prescriptions are either 65% of prescriptions are either inappropriate or incorrect.inappropriate or incorrect.
11 May, 2006
•• 66% (95% CI 54 66% (95% CI 54 –– 78%) 200478%) 2004•• 59% (95% CI 47 59% (95% CI 47 –– 72%) 200572%) 2005
11 May, 2006
Clinical OutcomesClinical Outcomes
•• Length of StayLength of Stay•• MortalityMortality•• Antimicrobial resistanceAntimicrobial resistance•• Infection ratesInfection rates•• Antibiotics expenditures & utilizationAntibiotics expenditures & utilization•• Hospital readmission ratesHospital readmission rates
11 May, 2006
Clinical OutcomesClinical Outcomes
•• Length of Stay Length of Stay •• MortalityMortality••• Antimicrobial resistanceAntimicrobial resistanceAntimicrobial resistance••• Infection ratesInfection ratesInfection rates••• Antibiotics expenditures & utilizationAntibiotics expenditures & utilizationAntibiotics expenditures & utilization••• Hospital readmission ratesHospital readmission ratesHospital readmission rates
11 May, 2006
OutcomesOutcomes
85.7 per 100085.7 per 1000
2.86 days2.86 days
3 days3 days3 days
Antibiotics Antibiotics appropriately appropriately usedused
p = 0.68p = 0.68125 per 1000125 per 100032.3 per 100032.3 per 1000MortalityMortality
p = 0.038p = 0.0384.6 days4.6 days2.47 days2.47 daysMean Length Mean Length of Stayof Stay
p = 0.016p = 0.016p = 0.0164 days4 days4 days2 days2 days2 daysMedian Median Median Length of Length of Length of StayStayStay
Antibiotics NOT Antibiotics NOT appropriately appropriately usedused
Antibiotics Antibiotics not usednot used
11 May, 2006
Antibiotics Stewardship Antibiotics Stewardship ProgrammeProgramme
•• Antibiotics Stewardship TeamAntibiotics Stewardship Team–– Infectious Disease SpecialistInfectious Disease Specialist–– MicrobiologistMicrobiologist–– PharmacistPharmacist–– Infection Control NursesInfection Control Nurses
11 May, 2006
Mortality RateMortality Rate
20
25
30
35
40
45
50
55
60
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Month of the year
Mor
tali
ty (
x 1/
1000
)
2001 2002 2003 2004 2005 2006
11 May, 2006
ConclusionConclusion
•• Appropriate antibiotic use is associated Appropriate antibiotic use is associated with shorter length of staywith shorter length of stay
•• Overall prescribing behaviour of clinicians Overall prescribing behaviour of clinicians did not change over the past yeardid not change over the past year
•• Active expertise participation in patient Active expertise participation in patient management is recommended for management is recommended for achieving appropriate antibiotic use and achieving appropriate antibiotic use and better outcomebetter outcome
11 May, 2006
AcknowledgementAcknowledgement
•• Dr. Dr. SzetoSzeto Ming LeungMing Leung•• Dr. Dr. QueQue TakTak LunLun
11 May, 2006
Thank you very muchThank you very much
